Nokea
When the nurse is instructing the client on the effectiveness of oseltamivir (Tamiflu), which of the following instruction points is essential?
- A. Tamiflu must be started within 12 to 24 hours of the first symptoms.
- B. Tamiflu must be taken on an empty stomach to aid in absorption.
- C. Tamiflu affects the liver; liver enzymes are assessed before administration.
- D. Tamiflu is most effective when administered intranasally.
Correct Answer: A
Rationale: Oseltamivir is most effective when started within 12 to 24 hours of symptom onset, as it inhibits viral replication early.
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When performing the client's tracheostomy care, which nursing action is correct?
- A. Cut a gauze square to fit around the client's stoma.
- B. Secure the ties at the back of the client's neck.
- C. Attach new ties before removing old ones.
- D. Replace the cannula after changing the ties.
Correct Answer: C
Rationale: Attaching new ties before removing old ones ensures the tracheostomy tube remains secure, preventing accidental dislodgement.
The client is diagnosed with bronchiolitis obliterans. Which data indicate the glucocorticoid therapy is effective?
- A. The client has an elevation in the blood glucose.
- B. The client has a decrease in sputum production.
- C. The client has an increase in the temperature.
- D. The client appears restless and is irritable.
Correct Answer: B
Rationale: Decreased sputum production (B) indicates reduced airway inflammation in bronchiolitis obliterans, suggesting effective glucocorticoid therapy. Elevated glucose (A) is a side effect, not efficacy. Increased temperature (C) or restlessness (D) suggests worsening or side effects, not improvement.
Which time of day is best for the nurse to obtain a sputum specimen from the client?
- A. Before bedtime
- B. After a meal
- C. Between meals
- D. On awakening
Correct Answer: D
Rationale: Sputum is most concentrated and easier to collect on awakening due to accumulation overnight.
A client comes to the clinic with a bloody nose. Which instruction is most appropriate?
- A. Sit up with your head tilted forward. Grasp the soft part of your nose firmly between your thumb and forefinger.'
- B. Lay down and tilt your head backward. Grasp the end of your nose between your fingers.'
- C. Sit up and lean backwards. Put pressure on the side of your nose with your hand.'
- D. Lie down with your head lower than your feet. Grasp as much of your nose as possible between your fingers.'
Correct Answer: A
Rationale: Sitting with the head tilted forward and grasping the soft part of the nose prevents aspiration of blood and effectively stops bleeding.
The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse?
- A. Large amounts of thick white sputum.
- B. Oxygen flowmeter set on eight (8) liters.
- C. Use of accessory muscles during inspiration.
- D. Presence of a barrel chest and dyspnea.
Correct Answer: B
Rationale: High oxygen (8 LPM, B) risks CO2 retention in COPD, requiring immediate adjustment (2–4 LPM). Sputum (A), accessory muscles (C), and barrel chest (D) are expected but less urgent.